In reply

Abstract

We appreciate the comments of Dr. Apiliogullari et al. about our article and their discussion about the diagnosis of postdural puncture headache (PDPH) following epidural blockade in pregnant women. 1 Vassal O. Baud M.C. Bolandard F. et al. Epidural injection of hydroxyethyl starch in the management of postdural puncture headache. Int J Obstet Anesth. 2013; 22: 153-155 Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar Like our colleagues, we agree that the definition of PDPH includes dural puncture. Accident dural puncture is identified by observing cerebrospinal fluid (CSF) at the hub of the epidural needle, aspirating CSF from the epidural catheter, observing rapid motor block following a local anaesthetic test dose or the onset of a high block. In our first patient, the epidural catheter insertion was uneventful and none of the features listed above was observed. Several studies have, however, reported a high percentage of unrecognised dural punctures. Davies et al. reported 92 dural punctures in 11462 labour epidurals in which 15 were unrecognised (16.3%). 2 Davies R.G. Laxton C.J. Donald F.A. Unrecognised dural punctures. Int J Obstet Anesth. 2003; 12: 142-143 Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar Furthermore, Sprigge et al. reported that the anaesthetist was unaware that an accidental dural puncture had occurred in 61 patients (36%) until the patient presented with a typical headache. 3 Sprigge J.S. Harper S.J. Accidental dural puncture and post dural puncture headache in obstetric anaesthesia: presentation and management: a 23-year survey in a district general hospital. Anaesthesia. 2008; 63: 36-43 Crossref PubMed Scopus (112) Google Scholar Thus, in a consistent number of cases, dural puncture cannot be eliminated by apparently uncomplicated epidural blockade.